Hyperangulated vs. Macintosh videolaryngoscopy in adults with anticipated difficult airway management: a randomised controlled trial

BACKGROUND

It is not certain whether the blade geometry of videolaryngoscopes, either a hyperangulated or Macintosh shape, affects glottic view, success rate and/or tracheal intubation time in patients with expected difficult airways. We hypothesised that using a hyperangulated videolaryngoscope blade would visualise a higher percentage of glottic opening compared with a Macintosh videolaryngoscope blade in patients with expected difficult airways.

METHODS

We conducted an open-label, patient-blinded, randomised controlled trial in adult patients scheduled to undergo elective ear, nose and throat or oral and maxillofacial surgery, who were anticipated to have a difficult airway. All airway operators were consultant anaesthetists. Patients were allocated randomly to tracheal intubation with either hyperangulated (C-MAC D-BLADE™) or Macintosh videolaryngoscope blades (C-MAC™). The primary outcome was the percentage of glottic opening. First attempt success was designated a key secondary outcome.

RESULTS

We assessed 2540 adults scheduled for elective head and neck surgery for eligibility and included 182 patients with expected difficult airways undergoing orotracheal intubation. The percentage of glottic opening visualised, expressed as median (IQR [range]), was 89 (69-99 [0-100])% with hyperangulated videolaryngoscope blades and 54 (9-90 [0-100])% with Macintosh videolaryngoscope blades (p < 0.001). First-line hyperangulated videolaryngoscopy failed in one patient and Macintosh videolaryngoscopy in 12 patients (13%, p = 0.002). First attempt success rate was 97% with hyperangulated videolaryngoscope blades and 67% with Macintosh videolaryngoscope blades (p < 0.001).

CONCLUSIONS

Glottic view and first attempt success rate were superior with hyperangulated videolaryngoscope blades compared with Macintosh videolaryngoscope blades when used by experienced anaesthetists in patients with difficult airways.

The role of supraglottic airway devices for caesarean section under general anaesthesia. A scoping literature review with a proposed algorithm for the appropriate use of supraglottic airway devices for caesarean sections

This review aims to assess the published evidence on airway management with a supraglottic airway device (SGA) for general anaesthesia in patients requiring a caesarean section. Physiological changes during pregnancy can make airway management in parturients challenging. At the same time, pregnant patients are at risk of pulmonary aspiration due to hormonal and mechanical alterations. The standard airway management for parturients undergoing caesarean section is rapid sequence induction followed by tracheal intubation. Evidence exists that using second-generation SGA devices is well tolerated and effective in selected patients. In this review, we provide an overview of the existing evidence and provide an algorithm to make an evidence-based clinical decision on the use of SGA devices. An online literature search was performed in Medline, Embase, PubMed, Emcare, Cochrane Library and CINAHL. The search terms used were 'supraglottic airway', 'supraglottic airway device', 'supraglottic airway management', 'supraglottic tube', 'i-gel', laryngeal mask', 'laryngeal mask airway', 'LMA', 'SGA', 'Proseal', 'Supreme', 'obstetric surgery', 'obstetric operation', 'general anaesthesia', 'caesarean' or 'caesarean section', 'abdominal delivery'. Full-text articles in English, Dutch and French were included. Case reports and studies in which the surgery was not a caesarean section were excluded. The initial search yielded 815 results. Following screening, deduplication and removal of publications that were unrelated to the topic or did not fit the inclusion criteria, 13 manuscripts were included in our analysis. A total of 7722 patients were described in the articles included. In the majority of manuscripts, second-generation SGA devices were used. There were seven cases of failed insertion and a need for conversion to tracheal intubation; first-generation SGA devices were used in these cases. There were no cases of pulmonary aspiration, and only one case of gastric regurgitation was described. Growing evidence suggests that the use of second-generation SGA devices might be well tolerated as the primary method for securing the airway for caesarean sections requiring general anaesthesia, in selected patients with a low risk for aspiration and difficult intubation.

Development and Evaluation of the Advanced Joint Airway Management System for Educational Utility in Endotracheal Intubation, as Assessed by Expert Paramedic Instructors

INTRODUCTION

Between 2011 and 2014, The Combat Casualty Training Consortium research study sought to evaluate all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among U.S. combat fatalities. This study identified a major training gap in critical airway management. To address this gap, the Advanced Joint Airway Management System (AJAMS) was designed and assessed for physical fidelity and educational utility in a population of paramedic instructors.

MATERIALS AND METHODS

Paramedic instructors served as participants in this prospective observational pilot study (n = 12). Participants interacted with three airway management trainers: The AJAMS trainer, the Laerdal Airway Management Trainer, and the TruCorp AirSim Advance Bronchi X Trainer. Participants then completed an evaluation of the trainer using a purpose-built data collection instrument that queried the trainer's realism and educational utility. Within-group differences were analyzed via a 1-way repeated measures ANOVA, with a Bonferroni post hoc analysis. Rank data were analyzed via non-parametric Freidman's test, and Wilcoxon signed-rank test post hoc analysis, corrected using the Bonferroni correction.

RESULTS

The AJAMS trainer conveys significantly more physical fidelity (visual: P < .001, ηp2 = 0.977; tactile: P < .001, ηp2 = 0.983; and behavioral: P = .001, ηp2 = 0.971) and overall educational utility (χ2(2) = 15.273, P < .001) than the two commercially available skill trainers.

CONCLUSIONS

These data suggest that physical fidelity is an important attribute in the design of simulators for health care, as perceived by expert instructors. These data illustrate that the AJAMS-integrated simulator demonstrates unparalleled physical fidelity, relative to commercially available airway management skill trainers.

Endotracheal Intubation Performance in Novices: Comparing the Training Effect Resulting From Two Airway Management Training Simulators

INTRODUCTION

Between 2011 and 2014, the Combat Casualty Training Consortium research study sought to evaluate all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among American combat fatalities. This study identified a major training gap in critical airway management. Because of the high rate of morbidity and mortality associated with poor or incorrect airway management, an effort to address this training gap was necessary.

MATERIALS AND METHODS

This experiment compared the training using the Advanced Joint Airway Management System, a novel high-fidelity airway simulator, relative to one of the most utilized simulators for endotracheal intubation (ETI) via a parallel group randomized control trial design. Before training, participants (n = 19) attempted an ETI on a cadaver using direct laryngoscopy. Performance during the attempt was recorded and scored by trained blinded raters. Participants were then randomly allocated to either novel or conventional training. Post-training, participants completed a second ETI under the same parameters. Analysis was completed via 2 × 2 mixed analysis of variance for (1) ETI Score, (2) Errors, (3) Critical Failures, and (4) Duration, across both the pre- and post-training tests and between the two groups.

RESULTS

A priori power analysis required a total sample size of 84 participants in this experimental design. Consequently, this study is under-powered to reach statistical significance. Scores for all trainees did improve with training, yet analyses did not reveal a difference in overall ETI score between the novel and conventional training group, at baseline or at the post-training test (P = .249).

CONCLUSION

The Advanced Joint Airway Management System simulator presents a training effect that is comparable to the conventional training model. However, given this study's small sample size, these results must be considered preliminary and further research is merited to draw firm conclusions about its impact on trainee performance. Future studies engaging larger cohorts of trainees and exploring the other capabilities of the Advanced Joint Airway Management System (cricothyroidotomy, needle chess decompression) are needed to further examine the educational potential of this novel airway management training system.

Effect of different lung recruitment strategies and airway device on oscillatory mechanics in children under general anaesthesia

BACKGROUND

Atelectasis has been reported in 68 to 100% of children undergoing general anaesthesia, a phenomenon that persists into the recovery period. Children receiving recruitment manoeuvres have less atelectasis and fewer episodes of oxygen desaturation during emergence. The optimal type of recruitment manoeuvre is unclear and may be influenced by the airway device chosen.

OBJECTIVE

We aimed to investigate the different effects on lung mechanics as assessed by the forced oscillation technique (FOT) utilising different recruitment strategies: repeated inflations vs. one sustained inflation and different airway devices, a supraglottic airway device vs. a cuffed tracheal tube.

DESIGN

Pragmatic enrolment with randomisation to the recruitment strategy.

SETTING

We conducted this single-centre trial between February 2020 and March 2022.

PARTICIPANTS

Seventy healthy patients (53 boys) aged between 2 and 16 years undergoing general anaesthesia were included.

INTERVENTIONS

Forced oscillations (5 Hz) were superimposed on the ventilator waveform using a customised system connected to the anaesthesia machine. Pressure and flow were measured at the inlet of the airway device and used to compute respiratory system resistance and reactance. Measurements were taken before and after recruitment, and again at the end of surgery.

MAIN OUTCOME MEASURES

The primary endpoint measured is the change in respiratory reactance.

RESULTS

Statistical analysis (linear model with recruitment strategy and airway device as factors) did not show any significant difference in resistance and reactance between before and after recruitment. Baseline reactance was the strongest predictor for a change in reactance after recruitment: prerecruitment Xrs decreased by mean (standard error) of 0.25 (0.068) cmH 2 O s l -1 per  1 cmH 2 O -1  s l -1 increase in baseline Xrs ( P  < 0.001). After correcting for baseline reactance, the change in reactance after recruitment was significantly lower for sustained inflation compared with repeated inflation by mean (standard error) 0.25 (0.101) cmH 2 O ( P  = 0.0166).

CONCLUSION

Although there was no significant difference between airway devices, this study demonstrated more effective recruitment via repeated inflations than sustained inflation in anaesthetised children.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12619001434189.

A Simpler Method for Choosing Adult i-gel Size: An Evaluation of Real-World Prehospital Data

OBJECTIVE

The i-gel supraglottic airway device (Intersurgical, Berkshire, UK) is commonly used in the United States and worldwide for prehospital airway management. Previous research has suggested that a sex-based method of size selection (4.0 for female patients and 5.0 for male patients) is superior to a weight-based method in patients undergoing elective anesthesia. Our objective was to compare a sex-based i-gel size selection strategy with a weight-based strategy using real-world prehospital data.

METHODS

The ESO Data Collaborative 2018 to 2022 dataset was used. All initial i-gel insertion attempts in patients > 18 years of age were evaluated for inclusion. Insertion attempts were excluded if age, sex, weight, success, or device size was not documented. Logistic regression was used to compare the rate of insertion failure on the first attempt for the group placed in alignment with the weight-based but not sex-based method with the group placed in alignment with the sex-based but not weight-based method.

RESULTS

After the application of the exclusion criteria, 39,867 initial i-gel insertion attempts were included. The overall rate of failure was 6.5% (2,585/39,867). The rate of unsuccessful i-gel placement was similar when i-gel devices were placed in alignment with a sex-based size selection method in comparison to i-gel placement in alignment with a weight-based selection strategy (6.0% vs. 6.4%). Logistic regression analysis did not reveal a significant difference between groups (odds ratio: 1.08; 95% confidence interval: 0.95-1.23).

CONCLUSION

The use of a sex-based method of i-gel size selection may be equivalent with respect to the rate of unsuccessful i-gel placement on the first attempt in comparison to a weight-based method.

Supraglottic airway device versus tracheal tube for pediatric laparoscopic surgery-A systematic review and meta-analysis

BACKGROUND

Conventionally, tracheal tubes have been used for general anesthesia in pediatric laparoscopic surgeries. Recently, supraglottic devices are being used for the same. The performance of supraglottic devices versus tracheal tubes in children undergoing laparoscopic surgery is uncertain.

METHODS

A systematic review and meta-analysis of randomized controlled trials that compared supraglottic devices versus tracheal tubes in patients ≤18 years undergoing laparoscopic surgery under general anesthesia was conducted. The outcomes were peak airway pressures (cm H2 O), end-tidal carbon dioxide during pneumoperitoneum (mm Hg), recovery time (min), postoperative sore throat and adverse events. Mean difference and odds ratio, with 95% confidence intervals were reported using a random effect model.

RESULTS

Eight trials (n = 591) were included in the final meta-analysis. There was no statistically significant difference in the peak airway pressures (MD 0.58, 95% CI: -0.65 to 1.8; p = .36) and end-tidal carbon dioxide (MD -0.60, 95% CI: -2.00 to 0.80; p = .40) during pneumoperitoneum in the supraglottic device and the tracheal tube group. The tracheal tube group had higher odds of sore throat (OR 3.30, 95% CI: 1.69-6.45; p = .0005) and the supraglottic airway group had faster recovery time (MD 4.21, 95% CI: 3.12-5.31; p < .0001), which were statistically significant. The certainty of evidence is graded low.

CONCLUSION

There is low quality evidence to suggest that for pediatric laparoscopic surgeries of short duration, supraglottic devices could provide comparable intraoperative ventilation in terms of peak airway pressures and end tidal carbon dioxide, with lower odds of postoperative sore throat and faster recovery time when compared to tracheal tubes.

Comparison of video laryngoscope, video stylet, and flexible videoscope for transoral endotracheal intubation in patients with difficult airways: a randomized, parallel-group study

BACKGROUND

The 2022 ASA guidelines recommend the video laryngoscope, video stylet, and flexible videoscope as airway management tools. This study aims to compare the efficacy of three airway devices in intubating patients with difficult airways.

METHODS

A total of 177 patients were selected and randomized into the following three groups: the video laryngoscope group (Group VL, n = 59), video stylet group (Group VS, n = 59), and flexible videoscope group (Group FV, n = 59). The success rate of the first-pass intubation, time of tracheal intubation, level of glottic exposure, and occurrence of intubation-related adverse events were recorded and analyzed.

RESULTS

All patients were successfully intubated with three devices. The first-pass intubation success rate was significantly higher in Groups VS and FV than in Group VL (96.61% vs. 93.22% vs. 83.05%, P < 0.01), but it was similar in the first-pass intubation success rate between Groups VS and FV(P > 0.05). The number of patients categorized as Wilson-Cormack-Lehane grade I-II was fewer in Group VL than in Groups VS and FV (77.97% vs. 98.30% vs. 100%, P = 0.0281). The time to tracheal intubation was significantly longer in Group FV(95.20 ± 4.01) than in Groups VL(44.56 ± 4.42) and VS(26.88 ± 4.51) (P < 0.01). No significant differences were found among the three groups in terms of adverse intubation reactions (P > 0.05).

CONCLUSIONS

In patients with difficult airways requiring intubation, use of the video stylet has the advantage of a relatively shorter intubation time, and the flexible videoscope and video stylet yield a higher first-pass intubation success rate and clearer glottic exposure than the use of the video laryngoscope.

TRIAL REGISTRATION

Chinese Clinical Trial Registry. No: ChiCTR2200061560, June 29, 2022.

Intubation using VieScope vs. Video laryngoscopy in full personal protective equipment - a randomized, controlled simulation trial

BACKGROUND

VieScope is a new type of laryngoscope, with a straight, transparent and illuminated blade, allowing for direct line of sight towards the larynx. In addition, VieScope is disposed of after single patient use, which can avoid cross-contaminations of contagious material. This has gained importance especially when treating patients with highly contagious infectious diseases, such as during the SARS-CoV2 pandemic. In this context, VieScope has not been evaluated yet in a clinical study.

MATERIAL AND METHODS

This study compared intubation with VieScope to video-laryngoscopy (GlideScope) in normal and difficult airway in a standardized airway manikin in a randomized controlled simulation trial. Thirty-five medical specialists were asked to perform endotracheal intubation in full personal protective equipment (PPE). Primary endpoint was correct tube position. First-pass rate (i.e., success rate at the first attempt), time until intubation and time until first correct ventilation were registered as secondary endpoints.

RESULTS

For correct tracheal tube placement, there was no significant difference between VieScope and GlideScope in normal and difficult airway conditions. VieScope had over 91% fist-pass success rate in normal airway setting. VieScope had a comparable success rate to GlideScope in difficult airway, but had a significantly longer time until intubation and time until ventilation.

CONCLUSION

VieScope and GlideScope had high success rates in normal as well as in difficult airway. There was no unrecognized esophageal intubation in either group. Overall time for intubation was longer in the VieScope group, though in an acceptable range given in literature. Results from this simulation study suggest that VieScope may be an acceptable alternative for tracheal intubation in full PPE.

TRIAL REGISTRATION

The study was registered at the German Clinical Trials Register www.drks.de (Registration date: 09/11/2020; TrialID: DRKS00023406 ).

All-fiber probes for endoscopic optical coherence tomography of the large airways

Endoscopic optical coherence tomography of large airways poses unique challenges. A hybrid lens is described that consists of a section of coreless fiber and graded index fiber (GIF), followed by a ball lens section. This design produces low numerical aperture beams better suited for large airway imaging. The performance of this lens is compared against conventional GIF and ball lens designs. Forward- and side-viewing probes were modeled, fabricated, and tested. The impact of a sheath on the beam profile was also investigated. Probes with working distances larger than 10 mm and depth-of-focus exceeding 12 mm are demonstrated with the proposed design.

Perception of level of knowledge, skills, and safety before and after training to perform videolaryngoscopy with the Intubox barrier system for airway management in patients with COVID-19

OBJECTIVES

The main objective was to describe physicians’ perception of their knowledge, skill, and safety before and after training to perform videolaryngoscopy while using the Intubox barrier system when managing the airway of a patient with the coronavirus 2019 disease (COVID-19). The secondary objective was to assess the safety afforded by the barrier by means of visually evaluating particle dispersion during intubation.

MATERIAL AND METHODS

Single-arm clinical simulation trial. The participants were physicians who received training in both a lowfidelity and a high-fidelity simulation zone. The participants assessed their knowledge, skill, and safety when using the Intubox before and after training using a specially designed and validated questionnaire. Droplet contamination was estimated visually.

RESULTS

Twenty-seven physicians with a mean (SD) age of 40 (10.8) years participated; 63% were women. They perceived their knowledge, skill, and safety to be significantly higher after training. Droplet contamination was seen to decrease when airway management maneuvers were done with the barrier in place.

CONCLUSION

After simulation training the emergency physicians judged their knowledge, skill, and safety to be greater when they used the barrier during airway management in patients with COVID-19. The combined use of a laryngoscope and the Intubox barrier resulted in less particle dispersion during intubation.

Comparison of airway management without neuromuscular blockers in laparoscopic gynecological surgery

New generation supraglottic airway devices are suitable for airway management in many laparoscopic surgeries. In this study, we evaluated and compared the ventilation parameters of the laryngeal mask airway-supreme (LM-S) and endotracheal tube (ETT) when a neuromuscular blocker (NMB) agent was not used during laparoscopic gynecological surgery. The second outcome was based on the evaluation of the surgical view because it may affect the surgical procedure.This was a randomized study that enrolled 100 patients between 18 and 65 years old with an ASA I-II classification. Patients were divided into 2 groups: Group ETT and Group LM-S. Standard anesthesia and ventilation protocols were administered to patients in each group. Ventilation parameters [airway peak pressure (Ppeak), mean airway pressure (Pmean), total volume, and oropharyngeal leak pressure] were recorded before, after, and during peritoneal insufflation and before desufflation, as well as after the removal of the airway device. Perioperative surgical view quality and the adequacy of the pneumoperitoneum were also recorded.The data of 100 patients were included in the statistical analysis. The Ppeak values in Group ETT were significantly higher in the second minute after airway device insertion. The Ppeak and Pmean values in Group ETT were significantly higher before desufflation and after removal of the airway device. No significant differences were found between the groups in terms of adequacy of the pneumoperitoneum or quality of the surgical view.The results of this study showed that gynecological laparoscopies can be performed without using a NMB. Satisfactory conditions for ventilation and surgery can be achieved while sparing the use of muscle relaxants in both groups despite the Trendelenburg position and the pneumoperitoneum of the patients, which are typical for laparoscopic gynecological surgery. The results are of clinical significance because they show that the use of a muscle relaxant is unnecessary when supraglottic airways are used for these surgical procedures.

COVID-19 Airway Management Isolation Chamber

OBJECTIVE

During the coronavirus pandemic (COVID-19), health care workers are innovating patient care and safety measures. Unfortunately, many of these are not properly tested for efficacy. The objective of this study was to determine the efficacy of the novel COVID-19 Airway Management Isolation Chamber (CAMIC) to contain and evacuate particulate.

STUDY DESIGN

Multi-institutional proof-of-concept study.

SETTING

Two academic institutions: Walter Reed National Military Medical Center (WRNMMC) and Madigan Army Medical Center (MAMC).

SUBJECTS AND METHODS

Smoke, saline nebulizer, and simulated working port models were developed to assess the efficacy of the CAMIC to contain and remove ultrafine particles. Particulate counts were collected at set time intervals inside and outside the system.

RESULTS

With the CAMIC on, smoke particulate counts inside the chamber significantly decreased over time: r(18) = -0.88, P < .001, WRNMMC; r(18) = -0.91, P < .001, MAMC. Similarly, saline nebulizer particulate counts inside the chamber significantly decreased over time: r(23) = -0.82, P < .001, WRNMMC; r(23) = -0.70, P < .001, MAMC. In the working port model, particulate counts inside the chamber significantly decreased over time: r(23) = -0.95, P < .001, WRNMMC; r(23) = -0.85, P < .001, MAMC. No significant leak was detected in the smoke, saline nebulizer, or working port model when the CAMIC was turned on.

CONCLUSIONS

The CAMIC system appears to provide a barrier that actively removes particles from within the chamber and limits egress. Further studies are necessary to determine clinical applicability. The CAMIC may serve as an adjunct to improve health care worker safety and patient outcomes.

Aerosol boxes and barrier enclosures for airway management in COVID-19 patients: a scoping review and narrative synthesis

Exposure of healthcare providers to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a significant safety concern during the coronavirus disease 2019 (COVID-19) pandemic, requiring contact/droplet/airborne precautions. Because of global shortages, limited availability of personal protective equipment (PPE) has motivated the development of barrier-enclosure systems, such as aerosol boxes, plastic drapes, and similar protective systems. We examined the available evidence and scientific publications about barrier-enclosure systems for airway management in suspected/confirmed COVID-19 patients. MEDLINE/Embase/Google Scholar databases (from December 1, 2019 to May 27, 2020) were searched for all articles on barrier enclosures for airway management in COVID-19, including references and websites. All sources were reviewed by a panel of experts using a Delphi method with a modified nominal group technique. Fifty-two articles were reviewed for their results and level of evidence regarding barrier device feasibility, advantages, protection against droplets and aerosols, effectiveness, safety, ergonomics, and cleaning/disposal. The majority of analysed papers were expert opinions, small case series, technical descriptions, small-sample simulation studies, and pre-print proofs. The use of barrier-enclosure devices adds to the complexity of airway procedures with potential adverse consequences, especially during airway emergencies. Concerns include limitations on the ability to perform airway interventions and the aid that can be delivered by an assistant, patient injuries, compromise of PPE integrity, lack of evidence for added protection of healthcare providers (including secondary aerosolisation upon barrier removal), and lack of cleaning standards. Enclosure barriers for airway management are no substitute for adequate PPE, and their use should be avoided until adequate validation studies can be reported.

Comparison of Supraglottic Airway Devices With Endotracheal Intubation in Low-Risk Patients for Cesarean Delivery: Systematic Review and Meta-analysis

BACKGROUND

The safety and adverse event rate of supraglottic airway (SGA) devices for cesarean delivery (CD) is poorly characterized. The primary aims of this review were to determine whether the first-pass success was higher and time to insertion for SGA was faster than endotracheal intubation for elective CD. The secondary aim was to determine the airway-related adverse event rate associated with SGA use compared to endotracheal intubation in elective CD under general anesthesia (GA).

METHODS

Six databases were systematically searched until September 2019. Included studies reported on the use of SGA in comparison to endotracheal tube intubation. A comparative meta-analysis between SGA and endotracheal intubation was performed using RevMan 5.3 software. Dichotomous outcomes were reported using an odds ratio (OR) with 95% confidence interval (CI). The results for continuous outcomes were reported using a weighted mean difference (WMD) with 95% CI.

RESULTS

Fourteen studies with 2236 patients compared SGA and endotracheal intubation. Overall, there was no statistically significant difference in first-attempt success rate (OR = 1.92; 95% CI, 0.85-4.32; I = 0%; P = .44). There was no clinically significant difference in time to insertion (WMD = -15.80 seconds; 95% CI, -25.30 to -6.31 seconds; I= 100%; P = .001). Similarly, there was no difference in any adverse event rate except sore throat which was reduced with the use of an SGA (OR = 0.16; 95% CI, 0.08-0.32; I= 53%; P < .001).

CONCLUSIONS

Despite the reasonable insertion success rate and safety profile of SGAs demonstrated in this meta-analysis, the analysis remains underpowered and therefore inconclusive. At present, further studies are required before the use of an SGA as the first-line airway for an elective CD can be recommended.

Time to adapt in the pandemic era: a prospective randomized non -inferiority study comparing time to intubate with and without the barrier box

BACKGROUND

The challenges posed by the spread of COVID-19 disease through aerosols have compelled anesthesiologists to modify their airway management practices. Devices such as barrier boxes are being considered as potential adjuncts to full PPE's to limit the aerosol spread. Usage of the barrier box raises concerns of delay in time to intubate (TTI). We designed our study to determine if using a barrier box with glidescope delays TTI within acceptable parameters to make relevant clinical conclusions.

METHODS

Seventy-eight patients were enrolled in this prospective non-inferiority controlled trial and were randomly allocated to either group C (without the barrier box) or the study group BB (using barrier box). The primary measured endpoint is time to intubate (TTI), which is defined as time taken from loss of twitches confirmed with a peripheral nerve stimulator to confirmation of end-tidal CO 2. 15 s was used as non-inferiority margin for the purpose of the study. We used an unpaired two-sample single-sided t-test to test our non- inferiority hypothesis (H 0: Mean TTI diff ≥15 s, H A: Mean TTI diff < 15 s). Secondary endpoints include the number of attempts at intubation, lowest oxygen saturation during induction, and the need for bag-mask ventilation.

RESULTS

Mean TTI in group C was 42 s (CI 19.2 to 64.8) vs. 52.1 s (CI 26.1 to 78) in group BB. The difference in mean TTI was 10.1 s (CI -∞ to 14.9). We rejected the null hypothesis and concluded with 95% confidence that the difference of the mean TTI between the groups is less than < 15 s (95% CI -∞ to 14.9,p = 0.0461). Our induction times were comparable (67.7 vs. 65.9 s).100% of our patients were intubated on the first attempt in both groups. None of our patients needed rescue breaths.

CONCLUSIONS

We conclude that in patients with normal airway exam, scheduled for elective surgeries, our barrier box did not cause any clinically significant delay in TTI when airway manipulation is performed by well-trained providers. The study was retrospectively registered at clinicaltrials.gov (NCT04411056) on May 27, 2020.

Laryngeal tubes and laryngeal mask devices for supraglottic airway management in out-of-hospital emergency care: a systematic review

Various supraglottic devices are currently available for airway management and are used widely in emergency situations because they are easy to position. We undertook a systematic review of the literature comparing laryngeal tubes and various laryngeal mask airway devices (LMAs) to determine which ones can be used most efficiently in emergencies. Nine databases were searched, as follows: Cochrane Library Plus, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Dialnet, Global Health, Nursing & Allied Health Database, CUIDEN, the Web of Science, and ScienceDirect. We collected studies published between 2014 and 2019 in Spanish, English, French, and Portuguese that compared laryngeal tubes to LMAs of different types for supraglottic airway management. Eighteen studies were selected for analysis after critical reading. Significant differences were not seen between tubes and LMAs with respect to most variables, but in certain contexts the oropharyngeal seal and speed of insertion were superior with laryngeal tubes; however, when fiberoptic bronchoscopes were then inserted the view of the glottis was poor. The different contexts in which these devices are used and the scarcity of studies comparing laryngeal tubes to LMAs does not allow us to identify clear differences among them with respect to efficiency. However, tubes seem to offer poorer visibility of the glottis according to evaluation with fiberoptic scopes, a factor to bear in mind if tracheal intubation, which is considered the gold standard, might become necessary.

Recommendations for Prehospital Airway Management in Patients with Suspected COVID-19 Infection

In light of the rapid spread of coronavirus disease 2019 (COVID-19) across the United States, the Centers for Disease Control and Prevention (CDC) and hospitals nationwide have developed new protocols to address infection control as well as the care of critical patients. Airway management has been particularly difficult; the challenge of quickly establishing an airway in patients must be balanced by the risk of aerosolizing respiratory secretions and putting the provider at risk of infection. Significant attention has been given to developing protocols for the emergency department and critical care units, but little guidance regarding establishing airway and respiratory support for patients in the prehospital setting has been made available. While some of the recommendations can be extrapolated from hospital guidelines, other factors such as environment and available resources make these protocols unfeasible. Through review of current literature the authors established recommendations regarding airway management and the provision of respiratory support to patients developing respiratory failure related to COVID-19.